VOLUNTEER APPLICATION
VOLUNTEER APPLICATION _______________________________________ _____________________________________ Name Date of Birth _______________________________________ _____________________________________ Social Security Number Phone Number ______________________________________________________________________________ Home Address ______________________________ City, State ___________________ Zip _______________________________________ E-mail Address _______________________________________ _____________________________________ Emergency Contact Relationship to Applicant _______________________________________ Emergency Phone Number EMPLOYMENT _______________________________________ _____________________________________ Employed By (If Employed) Phone Number ______________________________________________________________________________ Address May you be called at work? Yes No Brief description of work: ________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org EDUCATION Formal Education (highest year of school completed): ______________________________ Do you speak a foreign language? Yes No If yes, which language: _____________ AVAILABILITY Are you comfortable using a computer to fulfill your volunteer duties (typing and emailing court reports)? Yes No Do you have access to a secure computer either at work or at home? Do you drive? Yes No Yes No Do you have regular access to a car? Yes No Current community activities: ___________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ List current and previous volunteer work (list all previous volunteer work including brief description of duties and activities, dates of service.): ______________________________________________________________________________ ______________________________________________________________________________ As a CASA volunteer you will be required to attend court hearings for the children you represent. These hearings occur on Monday or Wednesday afternoons. Will you be able to arrange your schedule to attend these hearings? Yes No Are you willing to commit to one year of volunteer service? Yes No MOTIVATION What are your reasons for wanting to participate as a CASA volunteer? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org Have you had any personal experience(s) involving: Child Welfare Foster Care Court System Other agencies offering services to a child If so, please explain: ___________________________________________________________ ______________________________________________________________________________ How did you learn of our program: ______________________________________________ ______________________________________________________________________________ BACKGROUND Have you ever been convicted of a crime other than a traffic violation? Yes No If yes, what charge? __________________ Date convicted: ________ Where ____________ Do you consent to a routine check of your criminal records? Yes No Can you think of any reason why a judge might be reluctant for you to serve as a CASA volunteer? ___________________________________________________________________________ How long have you been a resident of Boyle/Mercer County? ______________________ How long have you been a resident of Kentucky? ________________________________ If you have lived in the state of Kentucky for less than five years, please provide us with the complete address of your last residence outside of Kentucky: Street address__________________________________________________________________ City____________________________ State__________________ Zip Code ______________ CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org Character References Please list three character references that have known you for at least two years and are NOT related to you by blood or marriage. Complete addresses are REQUIRED. 1. Full name __________________________ Phone _____________________________ Street Address___________________________________________________________ City ___________________________ State ____________ ZIP Code _____________ What is your relationship with this person?___________________________________ How long have you known this person? ______________________________________ 2. Full name __________________________ Phone _____________________________ Street Address___________________________________________________________ City ___________________________ State ____________ ZIP Code _____________ What is your relationship with this person?___________________________________ How long have you known this person? ______________________________________ 3. Full name __________________________ Phone _____________________________ Street Address___________________________________________________________ City ___________________________ State ____________ ZIP Code _____________ What is your relationship with this person?___________________________________ How long have you known this person? ______________________________________ CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org PLEASE RETURN YOUR COMPLETED APPLICATION ALONG WITH A PHOTOCOPY OF YOUR DRIVER’S LICENSE TO: CASA at Woodlawn 1153 Perryville Road Danville, KY 40422 (859) 936-3510 fax: (859) 936-3562 Please read the following statement before signing: I hereby certify that all information on this application is true and correct to the best of my knowledge. My signature below authorizes CASA at Woodlawn to make necessary checks to determine suitability to serve as a CASA Volunteer. This may include, but is not limited to, character reference checks, child abuse/neglect records, criminal records, sex offender registry checks and other individuals or agencies that may have knowledge of the applicant. These checks will be conducted before service begins and periodically for the duration of the volunteer’s service. All information collected will be held in the strict confidence. I understand that the program reserves the right to reject this application for any reason; and that any convictions or pending charges involving a sex offense, child abuse/neglect or related acts that in the program’s judgment would pose a risk to children or the program’s credibility, will result in the rejection of my application. _______________________________________________ Date ________________________________ (Applicant’s Signature) This section to be completed by CASA personnel only: CAN Registry: __________ Sent __________ Received AOC Records: __________ Sent __________ Received Sex Offender Registry: __________ Sent __________ Received Out of State Records: __________ Sent __________ Received (if applicable) Character References: Received: __________ Sent 1. __________ Interview held: 2. __________ ____________________ (date) Training completed: ____________________ (date) Badge made: 3. __________ by _______________________________ Oath taken: ______________________ (date) ____________________ (date) Application reviewed and certified complete by: _________________________________ (signature of CASA personnel) CASA at Woodlawn is committed to a policy of providing volunteer opportunities to all qualified people regardless of economic or social status and will not discriminate on the basis of race, color, ethic origin, national origin, creed, religion, political belief, sex, sexual orientation, marital status or age. CASA at Woodlawn is an equal opportunity agency. We encourage applications from women, minorities, and all interested and qualified people. CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org CASA at Woodlawn • 1153 Perryville Road • Danville, KY 40422 • 859.936.3510 • www.casaatwoodlawn.org
© Copyright 2024